Encephalopathy physical examination

Encephalopathy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Overview

Physical examination includes complete review of all the systems. Clues to diagnosis are obtained such as any fractures would indicate trauma as the cause, signs of liver failure identifies hepatic encephalopathy. In cases of lesions of brain, a complete neurological examination identifies the site of the lesion.

Appearance of the Patient

The appearance is mainly depends upon the severity of the condition and the cause. The patient is often confused. The patient may appear anxious and may have difficulty in breathing. Bad odor may be felt at times due to fetor hepaticus in hepatic encephalopathy. There may few signs of injury which may be due to trauma.

Vitals

Temperature

• Increased in infections, thyroiditis

• Decreased in severe sepsis

Pulse

Rate

• Tachycardia may be present in cases of thyroiditis and infections
• Bradycardia may be present in dehydration, loss of blood volume and severe sepsis

Rhythm

• The pulse is regular

Strength

• The pulse may be weak in cases of dehydration and hemorrhages

Symmetry

• The pulses are symmetric

Blood Pressure

• Hypotension may be present in cases of loss fluids , sepsis and low blood volume
• Hypertension may be present in cases of severe hypertensive encephalopathy

Respiratory Rate

• Tachypnea may be present in cases of pulmonary edema caused due to increase in blood pressure or due to multi organ failure

• Cheyne-Stokes respirations - an altered breathing pattern seen with brain damage and coma

Skin

• Cyanosis may be present in severe hypoxia and poisoning
• Jaundice may be present liver failure and in neonatal encephalopathy
• A rash may be present owing to a viral infection

Head

• No obvious signs on head.
• Skull fractures may be evident in cases of trauma

Eyes

• Icteric sclera may be present
• Nystagmus may be seen in a few cases of cranial nerve disease
• Papilledema, hemorrhages, exudates seen in hypertensive encephalopathy

Ears, Nose, Throat (ENT)

• No significant findings
• Injuries if trauma

Neck

• Jugular venous pressure may be elevated
• Thyromegaly may be present

Lungs

• Pulmonary edema and rales may be present
• Lung consolidation - in case of infections

Heart

• S1 Normal
• S2 Normal
• S3 may be heard in hypertensive cases

Abdomen

Significant abdominal findings are seen in hepatic encephalopathy

• Abdominal distention may be present
• Abdominal tenderenss may be present if any infections like spontaneous bacterial peritonitis
• An acute abdomen may be present
• Splenomegaly may be present in cirrhosis
• Abdominal pulsations can be noticed in hepatic encephalopathy

Extremities

• Edema may be noticed
• Cyanosis may evident in the patients of hypoxia

Neurologic

Complete neurological examination may not be possible in a few cases due to disoriented presentation. The results of examination help in identifying the sire of lesion. Complete neurological exam include assessment of mental status, cranial nerves, motor system , sensation and cerebellum. All the signs listed below may not be seen in all encephalopathy patients.

Mental status

• Assessment of consciousness by Glasgow Coma Scale , this determines the alertness of the patient.
• Assessment of higher functions like memory
• Assessment of mental status by Mini Mental Status Examination.

Cortical signs

• Psychomotor retardition
• Dementia
• Apraxia
• Mutism

These signs are seen in terminal stages of untreated encephalopathy.

Cranial nerves

• Nystagmus may be seen
• Visual acuity or visual field defects
• Facial nerve palsy
• Loss of ability to swallow
• Loss of ability to speak

Motor system

• Muscle atrophy and weakness
• Myoclonus (involuntary twitching of a muscle or group of muscles)
• Tremor
• Seizure
• No abnormal postures
• Hyperreflexia

Any other motor system signs point towards other differential diagnosis.

Sensations

• Sensory system is not frequently involved in encephalopathies

Cerebellum

• Ataxia may be present
• Nystagmus may be present
• Asterixis may be present
• Gait abnormalities may be present

References

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